Help!  my private health insurance company is denying coverage for breast implant removal, what can I do?

Private health insurance and breast implant removal

Help!  my private health insurance company won’t cover my breast implant removal, what can I do?

One of the more common questions we get here at Rise is whether your private health insurance will cover your breast implant removal.  

We have assisted women to get private health insurance funds for explant or implant surgery.

Here we discuss what you can do if you have this problem.

Be aware that this is general information only, and your private health insurance policy will  have its own criteria for coverage.

We will take a look at four steps so you can give yourself the best chance of private health coverage for your surgery:

Step 1 - check your health policy

Step 2 - document everything

Step 3 - check if Medicare covers you

Step 4 - don’t give up

So, let’s get started…


Your private health policy should tell you whether certain procedures are covered …

Step 1 - Check the wording of your policy

As Australians we generally enjoy a high standard of healthcare, and there are a number of insurance policies out there which will  pay for your surgical costs relating to breast implant removal, as well as other hospital expenditure, provided that you take the right steps before your explant procedure. These private health insurance companies include Bupa, HBF, HCF, Medibank, AAMI and NIB.

Each of these policies publish a list of the surgical procedures that they cover, and you should have a private health insurance policy that details the level of coverage that you have.  

You can ask your private health insurance company for a copy of that policy and this will help you understand what type of procedures are covered under that policy, and whether you are likely to be covered for explant.

You may have many reasons for wanting your breast implants removed, but if those reasons don't fit under the policy,  then your insurance company won't make a payment for you to have them removed.

For example,  if you are worried about suffering from bia-alcl this alone may not be enough to allow you coverage under the private health policy, however certain other conditions might be, which are detailed in the policy.

Step 2 - Document everything

You should be aware that private health insurance companies need evidence to fit the coverage within their policy. This evidence will need to be generated from medical specialist, and general practitioners.

The key is to be aware that you want to have everything recorded and documented and that being proactive is an important step in protecting your rights.

It is important to start a medical paper Trail.

So, it is important that you are aware that you will need to consult with  various medical specialists And that these medical specialists will need to provide documentation, such as medical reports, certificates, and other forms as evidence to show that the procedure should be covered under the policy.

Often the private health insurance company will have a certain form contained on their website which  your medical specialist can fill in, in order to support your claim for coverage under the policy.

Step 3 - Does Medicare cover your procedure?

Often private health insurance companies will cover surgeries which are ordinarily covered by Medicare already.

We have looked into the various procedures that are covered by Medicare in relation to breast implant illness in this detailed article.   

A number of private health insurance companies have been shown to provide coverage where certain documents have been provided which showed that the surgery is medically necessary. So, it's important to have a supportive surgeon, who does believe that the explant procedure is medically necessary and is willing to provide you with medical evidence to demonstrate that position.

Be aware that certain Medicare codes are covered which relate to breast implant removal, for example the explant 45551 code will generally cover part of the surgery for breast implant removal, through Medicare.

However, you should be also aware that if that code is used  in your clinical referral with a different code, for example with a code for a breast surgical lift, your private health insurance may refuse coverage on the basis that it is a primarily cosmetic procedure rather than medically necessary.

Step 4 - Don't give up!


many women who were denied coverage were later reimbursed, so it pays to be persistent

Be aware that a number of women have initially had coverage refused, and then overturned on appeal, so it can often be worth trying a few times in order to get access to the policy.

For example, one woman initially had her policy refuse coverage, and was looking at an $11,000 fee for explant surgery, however when she was able to gather the right medical documents to support her position, she was only charged $6,000 out of pocket and was very happy with that result.

We take a look at what steps you can take if you have an initial denial for coverage from an insurance company in this article.

Give us a call

We care about Australian women and we are proud to help Australian women gain access to the private health insurance for issues relating to breast implants, so give us a call on 0413 634 739 today.

We won’t charge you for the first consultation, so you have nothing to lose.

Or take a look at our other helpful articles below, or search here for other articles on breast implants and how we can help you.